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COMPLICATIONS OF CATARACT SURGERY

1. Operative complications
Vitreous loss
Posterior loss of lens fragments
Suprachoroidal (expulsive) haemorrhage
2. Early postoperative complications
Iris prolapse
Striate keratopathy
Acute bacterial endophthalmitis
3. Late postoperative complications
Capsular opacification
Implant displacement
Corneal decompensation
Retinal detachment
Chronic bacterial endophthalmitis
Operative complications of vitreous loss
Management

Sponge or automated anterior vitrectomy


Insertion of PC-IOL if adequate casular support present
Insertion of AC-IOL
If adequate capsular support absent

1. Constriction of pupil
4. Coating of IOL
2. Peripheral with viscoelastic
iridectomy substance
3. Glide insertion

5. Insertion of IOL 6. Suturing of


incision
Management of posterior loss of lens fragments
Fragments consisting of 25% or more of lens should be removed

Pars plana vitrectomy and removal of fragment


Management of suprachoroidal
(expulsive) haemorrhage
Close incision and administer hyperosmotic agent
Subsequent treatment after 7-14 days

Drain blood
Pars plana vitrectomy
Air-fluid exchange
Early postoperative complications
Iris prolapse
Cause
Usually inadequate
suturing of incision
Most frequently follows
inappropriate management
of vitreous loss

Treatment
Excise prolapsed iris tissue

Resuture incision
Striate keratopathy
Corneal oedema and folds in Descemet membrane

Cause
Damage to endothelium
during surgery

Treatment
Most cases resolve
within a few days

Occasionally persistent
cases may require
penetrating
keratoplasty
Acute bacterial endophthalmitis
Incidence - about 1:1,000

Common causative
organisms
Staph. epidermidis
Staph. aureus
Pseudomonas sp.

Source of infection
Patients own external
bacterial flora is most
frequent culprit
Contaminated solutions
and instruments
Environmental flora including
that of surgeon and
operating room personnel
Preoperative prophylaxis
Treatment of pre-existing infections

Staphylococcal blepharitis Chronic conjunctivitis

Chronic dacryocystitis Infected socket


Peroperative prophylaxis

Meticulous prepping and draping

Postoperative injection of
Instillation of povidone-iodine antibiotics
Signs of severe endophthalmitis

Pain and marked visual loss Absent or poor red reflex


Corneal haze, fibrinous exudate and Inability to visualize fundus with
hypopyon indirect ophthalmoscope
Signs of mild endophthalmitis

Mild pain and visual loss Small hypopyon


Anterior chamber cells Fundus visible with indirect
ophthalmoscope
Differential diagnosis of endophthalmitis
Uveitis associated with Sterile fibrinous reaction
retained lens material

No pain or hypopyon No pain and few if any anterior cells


Posterior synechiae may develop
Management of Acute Endophthalmitis

1. Preparation of intravitreal injections


2. Identification of causative organisms
Aqueous samples
Vitreous samples

3. Intravitreal injections of antibiotics

4. Vitrectomy - only if VA is PL
5. Subsequent treatment
Preparation for sampling and injections

Antibiotics Mini vitrector


Sampling and injections (1)

Make partial-thickness sclerotomy Insert mini vitrector


3 mm behind limbus
Sampling and injections ( 2 )

Insert needle attached to syringe


containing antibiotics Remove vitrector and needle
Aspirate 0.3 ml with vitrector
Inject subconjunctival antibiotics
Give first injection of antibiotics
Disconnect syringe from needle
Give second injection
Subsequent Treatment
1. Periocular injections
Vancomycin 25 mg with ceftazidime 100 mg
or gentamicin 20 mg with cefuroxime 125 mg

Betamethasone 4 mg (1 ml)

2. Topical therapy
Fortified gentamicin 15 mg/ml and vancomycin 50 mg/ml drops
Dexamethasone 0.1%

3. Systemic therapy
Antibiotics are not beneficial
Steroids only in very severe cases
Types of capsular opacification
Elschnig pearls Fibrosis

Proliferation of lens epithelium Usually occurs within 2-6 months


Occurs after 3-5 years May involve remnants of anterior
capsule and cause phimosis
Treatment of capsular opacification
Nd:YAG laser capsulotomy
Accurate focusing is vital
Apply series of punctures
in cruciate pattern (a-c)
3 mm opening is adequate (d)

Potential complications
Damage to implant
Cystoid macular oedema
- uncommon
Retinal detachment
- rare except in high myopes
Implant displacement
Decentration Optic capture

May occur if one haptic is inserted Reposition may be necessary


into sulcus and other into bag
Remove and replace if severe
Corneal decompensation
Predispositions Treatment

Anterior chamber implant Penetrating keratoplasty in severe cases


Fuchs endothelial dystrophy Guarded visual prognosis because
of frequently associated CMO
Retinal detachment risk factors

Disruption of posterior capsule Lattice degeneration

Intraoperative vitreous loss Treat prophylactically before or


Laser capsulotomy, particularly soon after surgery
in high myopia
Chronic bacterial endophthalmitis
Signs

Late onset, persistent, low-grade Low virulence organisms trapped


uveitis - may be granulomatous in capsular bag
Commonly caused by P. acnes or Staph. White plaque on posterior capsule
epidermidis
Treatment of chronic endophthalmitis

Initially good response to topical Recurrence after cessation of treatment


steroids Inject intravitreal vancomycin
Remove IOL and capsular bag if
unresponsive